This page was created in the days following the loss of our dog Scrappy, who suffered first from Congestive Heart Failure (CHF), then Chronic Renal Failure (CRF). My husband and I aren't vets; we're simply grieving owners who want to share the lessons we learned in hopes that others -- particularly in the UK -- don't lose their pets to a similar lack of information, as we did.

If you're here because your canine best friend has been afflicted with CRF or CHF, please take heart and read on. You'll find lots of valuable information and links to help you understand these diseases and how to ensure your dog has the best chance for a happy and prolonged life.

On behalf of Scrappy and your own precious pup, thank you for visiting this site.

Update on Pimobendan (Vetmedin) availability in the USA

Terrific news from the FDA website!

May 16, 2007 -- FDA Approves New Drug for Heart Failure in Dogs

The Food and Drug Administration announced today the approval of Vetmedin (pimobendan), a new drug for the management of the signs of mild, moderate, or severe (modified New York Heart Association Class II, III, or IV) congestive heart failure in dogs due to atrioventricular valvular insufficiency or dilated cardiomyopathy. Vetmedin, a new molecular entity, is the first drug approved to treat congestive heart failure in dogs, in over ten years. Vetmedin is indicated for use with concurrent therapy for congestive heart failure (e.g., furosemide, etc.) as appropriate on a case-by-case basis.

Congestive heart failure is one of the more common heart problems seen in dogs, especially older smaller breeds. It is a complex and serious condition defined as the heart's inability to function normally, leading to excessive retention of water and salt causing fluid build-up in the lungs. Signs of congestive heart failure include fatigue and weakness, decreased ability to exercise, shortness of breath (fluid build up in the chest), increased respiratory rate, coughing, weak or irregular pulses, rapid or irregular heart beats and distended abdomen (fluid build up in the abdomen).

Vetmedin helps alleviate signs of heart failure by increasing contractility (the force of heart muscle contraction) and by dilating blood vessels (decreasing resistance to blood flow).

Congestive heart failure is classified by a veterinarian according to clinical signs (Class II through Class IV). Class II is mild (fatigue, shortness of breath, coughing, etc. apparent when ordinary exercise is exceeded); Class III, moderate (comfortable at rest, but exercise capacity is minimal), and Class IV, severe (no capacity for exercise and disabling clinical signs are present even at rest).

The effectiveness and safety of Vetmedin were evaluated in a 56-day, multi-site, active controlled field study with pivotal success determined at Day 29. Three hundred fifty-five (355) dogs with modified New York Heart Association Class II, III, or IV congestive heart failure in dogs due to atrioventricular valvular insufficiency or dilated cardiomyopathy were randomly assigned to either the Vetmedin treatment group or the active control Enacard (enalapril maleate) treatment group. Treatment success at Day 29 in the Vetmedin group (80.7%) was determined to be non-inferior to the treatment success in the Enacard group (76.1%).

Adverse reactions associated with Vetmedin (and Enacard) were potentially related to congestive heart failure, the therapy of congestive heart failure, or both and included poor appetite, lethargy, diarrhea, worsening signs of heart failure, heart failure death, azotemia (increase in the blood urea nitrogen), and mild increases in serum liver enzymes.

Pimobendan is not for use in cats and is only for use in dogs with clinical evidence of heart failure due to atrioventricular valvular insufficiency or dilated cardiomyopathy. Pimobendan acts to alleviate the clinical signs of congestive heart failure, rather than to reverse the underlying cardiac pathology, and it does not replace the need for other appropriate concurrent heart failure therapy (diuretics, antiarrhythmic drugs, etc.).

Vetmedin is manufactured by MEDA Manufacturing GmbH, Cologne, Germany for Boehringer Ingelheim Vetmedica, Inc. of St. Joseph, Missouri.

For more information on Vetmedin, please see http://www.fda.gov/OHRMS/DOCKETS/98fr/2007-141-273-fois001.pdf.

November 2005:

It appears that US trials with Vetmedin/pimobendan, including those at Texas A&M University, have concluded and the results are with the FDA for approval. Seeing as Vetmedin has now been approved for use in Canada, Europe and Australia after long trials, there's reason to hope the FDA will follow suit.

As recently as last month the FDA was still allowing imports of pimobendan and some vets were prescribing it. If you live in the US and your dog has CHF, please consult with a vet or a specialist about the possibility of trying pimobendan. As with any drug, many factors must be taken into account by a qualified professional before pimobendan can be prescribed. For more information about pimobendan, please read Scrappy's story and see the links below.

2004 belated update:

I'm very sorry to report that Heather's dog Zach (see below) succumbed to CHF around Christmas-time. However, he did so well for the several months he was taking pimobendan that during a trip to the beach in June '04 he was able to romp around like his old self. Zach was seven years old.

10 March 2004:

There is hope on the horizon! Heather, from Southern California, has been successful in getting Vetmedin (generic name pimobendan) imported into the States from Canada, with FDA approval.

Heather's dog Zach was diagnosed with dilated cardiomyopathy -- a form of CHF -- on December 23, 2003, and given 6-8 months to live. After being told that Vetmedin looked promising but wasn't available in the USA, Heather began a determined effort to obtain the medicine for Zach. Within 10 days of coordinating paperwork between Zach's cardiologist, a Canadian pharmacy and the FDA, Zach was adminstered his first dose of Vetmedin on or about 6 March 2004, and at last report had stopped coughing and was eating again!

Here is what Heather says about acquiring Vetmedin:

"I obtained the medicine through PetPharm in Ontario. They are very helpful. However, anyone who is interested in going this route will need to have their cardiologist contact the FDA and fill out a questionnaire to get the special permission for import. Make sure that they remind PetPharm [or other Canadian pet pharmacy] to put a copy of the FDA's approval in with the shipment for US Customs at the border. They can fill an order for three months at a time and it's not as expensive as other medications.

"My cardiologist here in L.A. is Dr. Karen Sanderson at the Advanced Veterinary Care Center in Lawndale -- their number is (310) 679-4988. They are HIGHLY caring and professional, I would recommend them without hesitation."

Heather adds that anyone living near Texas A&M University (College Station, TX) can get more information about the Vetmedin research being conducted there by Dr. Sonya Gordon, but only through a referral by a veterinary cardiologist; Dr. Gordon won't take calls. Dr. Gordon has the most experience with Vetmedin's use in the USA and may also be able to help with dosage.

More advice from Heather:

"The cardiologist will have to work with the FDA to gain approval each time the drug is imported. Pet owners should be ready to pitch in and help do some leg work such as calling the FDA, collecting information and researching sources from which to purchase Pimobendan/VetMedin. Anything they can do to help move the process along will help cardiologists with a busy practice (they should appreciate it)."

For those who are skeptical about interacting with the FDA: don't be. Heather's experience with the agency is that they are very willing to facilitate the import process, and they moved quickly!

Please remember that to be eligible for Vetmedin, your CHF pet must first be seen by a specialist who then agrees to trial the drug. I'm not certain, but I don't think regular vets will do this. If your pet has CHF and the Enalapril/Lasix treatment prescribed by your vet isn't working or the possible side effects of these medicines concern you, please ask your vet for a referral to a cardiologist. There's more about seeking referrals here.

Also, American pet pharmacies will not have Vetmedin; you'll need to approach a Canadian pet pharmacy. I'm plugging PetPharm here because they were so helpful in Zach's case, but there's nothing to say another Canadian pet pharmacy won't be just as helpful.

Scrappy's Story

Scrappy, our beloved Cairn Terrier mix, was found as a stray in Van Nuys, California. At 4 years old she was diagnosed with a small heart murmur during a routine check-up. I was told this wouldn't pose a problem until her senior years. At 7 she moved with me to England and endured six months of quarantine with no adverse effect.

At 11, Scraps began to cough when exerted. Her British vet found that her heart murmur had worsened and diagnosed the beginnings of congestive heart failure. Scrappy began taking 20mg Frusecare (generic name frusemide, diuretic) daily to help reduce fluid build-up around her lungs. Every three months Scrappy had a check-up before a refill of Frusecare was prescribed. The check-up consisted of listening to her heart and enquiring after her general health. The Frusecare was gradually increased to 40mg a day.

Approximately a year later, when Scrappy's coughing picked up again, the vet added 5mg Enacard (generic name enalapril, heart medication) per day. Scrappy's three-month check-ups continued unaltered. At no time was a blood test ever done, nor were we informed one should be done, except in regards to securing a Pet Passport (rabies titre check).

In September 2001, at age 13, Scrappy's cough returned again. The vet added 25mg per day of Moduretic, another diuretic, to her regimen of Frusecare and Enacard. We were told the Moduretic would help the Frusecare to work more efficiently at removing fluids from Scrappy's body. I had also noticed she had recently developed very bad breath. The vet attributed it to old age and bad teeth.

Scrappy stopped coughing almost at once on the Moduretic. She remained bright and energetic (she was often mistaken for a much younger dog), but had noticeably lost weight after only two weeks. The vet attributed this to the loss of water weight. Again I mentioned her bad breath and how Scraps was now refusing some of her usual treats and food. After a discussion with the vet I went home with a toothbrush for Scrappy.

Within a month, Scrappy grew lethargic and began sleeping more, and very deeply. Finally, over the course of a few days she stopped eating altogether. She began to vomit and developed diarrhea. When we discovered her mouth was bleeding we called an emergency vet, who diagnosed her with gastritis. We were told to bring her in the next day, where a different vet pressed her abdomen and made a cursory check of her teeth. Scraps was put on Synulox, an antibiotic, to fight what was believed to be an intestinal bug.

Two days later, Scrappy was no better. She saw another vet, who reacted to the smell of her breath and the bleeding from her gums. For the first time in nearly two years a blood test was done. The results the next morning verified the vet's fear: Scrappy was in renal failure. Her Urea (BUN) and Creatinine levels, indicators of toxin levels in her blood, were off the charts.

Scrappy began on IV fluid treatment at the vets that day. Daily blood labs were done but only her Urea (BUN) and Creatinine levels were checked. Knowing phosphorous and electrolyte levels were important from our reseach into renal failure on the Internet, we requested a full blood panel, mistakenly believing 'full' meant everything. The results did not include phosphorous.

After five days on IV fluids, Scrappy's toxin levels had come down enough to release her. Her heart medicine was changed from 5mg Enacard/day to 5mg Fortekor/day, another heart drug which is unproven in dogs but has shown to help cats in renal failure. The Moduretic was stopped but she continued on 40mg Frusecare/day, plus 3ml Antepsin and 3ml Tagamet (liquids) to calm her toxin-irritated stomach, along with Synulox to fight infection. She was also put on a low protein diet of Hill's k/d prescription dog food.

Nine days later Scrappy had a check-up with another vet. She had been eating and seemed well. The vet listened to her heart and at our request took blood to check her phosphorous level specifically, as well as Urea (BUN) and Creatinine. Because they had to send out for the phosphorous test we were told to call back in three days for the results.

Before the results returned, Scraps had grown weak and stopped eating again. She began to vomit. The vet did a quick blood test of Urea (BUN) and Creatinine, which were off the charts again. She was re-admitted and put back on IV fluids. We enquired about the possibility of giving her subcutaneous fluids at home after her release, something we had a read a lot about on the Internet. The vet appeared unfamiliar with sub-q therapy and said it wasn't their usual practice. After being told twice 'the prognosis is not good', we pushed the sub-q subject until we were offered a referral to a specialist in small animal medicine.

Scrappy was transferred to specialist care two days later. Her doctor, a PhD with a long list of veterinary certifications, checked Scraps over thoroughly while we were there. He determined she was arrhythmic on top of having a very bad heart murmur, and thought her congestive heart failure might be in part responsible for the failure of her kidneys. He was straightforward in telling us that her two conditions required opposite treatments (kidney failure needs fluid therapy, congestive heart failure needs the removal of fluids), and that this would be a difficult -- perhaps impossible -- balance to make. But he saw hope. She was placed on IV fluids and given a battery of tests, including an x-ray and ultrasound of her heart and kidneys. Her cardiologist put her on a new heart medicine being trialed in the UK called Vetmedin, because it generally doesn't require the addition of a diuretic to aid in fluid removal. [Note: see above regarding Vetmedin (generic name pimobendan) availablity in the US.]

Two days later we visited Scrappy and found her energetic and playful in a way we hadn't seen since before she had gotten sick a month earlier. Her heartbeat felt strong and regular. Her cardiologist and kidney specialist talked at length with us about her prognosis. They were hopeful that they had managed to gain a little time for Scrappy, but wanted to keep her on IV fluids for some days yet as her toxin levels were still high. Christmas was three days away and we expressed the desire to have her home by then, but we agreed that if it was in Scrappy's best interest to stay over Christmas to get the full benefit of the treatment she was on, that's what she would do.

Two nights later, the doctor called to say Scrappy had collapsed. She had come around again, but it wasn't good. They wouldn't know how serious it was till the next morning (Christmas eve).

The next morning the doctor called and informed us that Scrappy was doing poorly. She was having difficulty breathing, her toxin levels had not come down appreciably nor was she eating yet, and she was generally very sick and sad. He had said from the start that he would let us know when he felt they had done all they could without causing her to suffer, and those were the words he used now.

That day, December 24, 2001, we visited our baby one last time. She was coughing badly and could not stand up, though she still had the energy to wag her tail for ten minutes as we cuddled and spoke to her. We stayed to comfort her as the doctor put her to sleep.

CRF, CHF and treatments

Chronic Renal Failure (CRF) is a progressive decline in kidney function due to the wearing out of the kidneys. Toxins gradually build up in the pet's bloodstream because the kidneys are no longer able to filter them out. Old age is the number one cause, but it can also be genetic or precipitate from the giving of certain drugs that work the kidneys hard, like diuretics. Enacard (enalapril) is also known to precipitate kidney failure. For this reason, pets of any age who are on Enacard and/or a diuretic should have regular blood tests done to check kidney function.

CRF has few observable symptoms in its initial stage, and the symptoms come on so slowly as toxin levels build that in most cases they go unnoticed. Pets can have CRF but act completely normal. The only way to find the disease before irreversible kidney damage is done is through regular blood tests in any dog taking medications that risk precipitating renal failure. Additionally, all good vets suggest that every senior dog (8 years +) has a 6-month/annual blood test to check kidney function.

Some of the symptoms of CRF are: increased drinking/urination; anemia; lethargy or exercise intolerance; loss of appetite or unusual pickiness; vomiting; diarrhea; bleeding or ulcerous gums; 'ammonia' or otherwise very strong rancid bad breath. A pet may exhibit only one or two of these symptoms which can easily be mistaken for something less dramatic, like gastritis. Most of the symptoms associated with renal failure are due to the high toxin levels that build up in the pet's bloodstream. The vet who discovered it in Scrappy likened it to "feeling as if you had a permanent bad hangover".

Increased thirst and 'accidents' around the house are usually the first symptoms, which can be masked by any diuretic your pet is taking. There is no test to determine if your pet is likely to suffer renal failure.

CRF cannot be cured. Its progression can only be slowed, if caught in time, through strict dietary management and the addition of fluid treatment in its final stage. Subcutaneous fluid treatment (sub-q) can be done at home to help maintain kidney function, but it isn't as widely accepted in the UK as it is in the US.

Dogs with CRF don't fair as well as cats, but depending on the stage it's caught at there's no reason to give up on your canine friend. An early diagnosis, aggressive treatment and most importantly your TLC and adherence to proper diet can translate into months if not years of a healthy and active life for your pet to enjoy.

Congestive Heart Failure (CHF) is the build-up of fluids in and around the lungs and other organs due to inefficient heart function. Like CRF, CHF is a progressive, incurable disease and has many causes. CHF occurs commonly in small dogs, who are especially susceptible to heart murmurs and therefore at greater risk of suffering problems due to a weakening heart in old age.

One of the first symptoms of CHF is a moist, sometimes gagging cough in an exerted or excited pet. This may be accompanied by exercise intolerance, a general lack of energy, and sometimes fainting spells. The CHF cough can easily be mistaken for kennel cough. Only a vet can determine if your pet has CHF.

If your dog has or is at risk for CHF, one of the best things you can do at home is to reduce and carefully monitor his sodium (salt) intake. Sodium causes water retention, the one thing your CHF pet doesn't need. Even if your dog is healthy, keep him that way longer by putting him on a strict low-sodium diet now and stop feeding table scraps -- human food is loaded with salt (which isn't good for us either). If your dog turns his nose up, substitute a little low-sodium salt or add garlic powder (NOT garlic salt) to enhance flavour.

Helpful hint: if your dog has regular coughing fits while eating or (more commonly) drinking, try placing the food and water dishes up on a platform to raise them to your pet's chest level. Not having to bend down so far will reduce the stress on his heart and lungs, which should ease the cough reflex.

Your vet may prescribe a diuretic to help shift fluids from the body, and/or heart medicine to help the heart pump blood more efficiently, further aiding the removal of fluids and enhancing overall health. Enacard (also known as Vasotec, generic name enalapril) is currently one of the most popular heart medications for dogs with CHF. It is often prescribed alongside a diuretic. Enacard's benefits are proven, but it does come with the risk of inducing kidney (renal) dysfunction. Therefore, any dog placed on a diuretic and/or Enacard should have an initial blood test to check kidney function, another blood test 7-10 days after starting the drug(s), and thereafter on a regular basis.

For more information on these diseases, please see the links provided below.

Advice and Hints

1. If your dog is put on Enacard (enalapril) or a diuretic, demand regular blood tests if your vet isn't already doing them. Senior dogs (8 years +) should have regular blood tests regardless of their health as preventive medicine. The sooner CRF is caught, the more can be done to improve your pet's quality of life and longevity.
   
   
2. Ask questions. If your vet is standoffish or less than cooperative with you, don't be afraid to push the subject with them. For example, you have a right to see blood test results -- you're paying for them! If you still aren't happy, or your vet just doesn't seem to have the time to answer your questions, request another vet from the same group or find another in the area.
   
   
3. Research your pet's ailment online. Knowledge is power, and the Internet is a treasure trove of information (albeit one that you should use for gaining general, not specific, knowledge). You'll also find many other owners online who have dealt with the same thing and have advice that may come in handy to you, particularly when it comes to caring for your CRF/CHF pet at home. The links we found useful are listed below.
   
   
4. Investigate any drug you're giving your pet. Again, the Internet is an invaluable tool. We will forever regret not researching Enacard when Scrappy started on it to ensure she got the necessary blood tests.
   
   
5. If your pet isn't covered by health insurance, do it now. It costs so little, and in the long-run will enable you to afford any treatment your pet may need if he develops CRF or CHF in his senior years. PetPlan is a good one in the UK, and application forms are available at most veterinary surgeries.
   
   
6. Remember, you can't make an informed decision for your pet if you aren't informed. In the UK we found some vets, including the younger ones, were reluctant to share information, evidently because they felt it might confuse us. Some may even give up on your pet out of the unspoken belief that you won't want to undertake the cost or rigor of an available treatment. A good vet is one who is willing to explain what is going on with your pet in as much detail as you need, and outline all the treatment options -- including the expensive ones -- in a frank but compassionate manner.
   
   
7. If your vet is unwilling to consider a treatment that you feel might benefit your pet (such as subcutaneous fluid injections, or trial drugs like Vetmedin), seek a referral. In fact, any time you feel your pet isn't getting the best treatment possible ask for a referral! This will tell your vet you're serious about treating your pet's condition, and may prompt them to action. If not, expensive as a specialist may be, it can be well worth it for your peace of mind...and often a portion of the fees can be recouped through insurance.
   
   
8. Any time your pet's behavior niggles at the back of your mind as somehow out of character, SEE A VET. Have blood work done if your pet doesn't improve or you become at all doubtful of your vet's diagnosis. Better yet, get a second opinion.

Links (all open new browser windows)

About CHF (Congestive Heart Failure) and Treatments

University of Illinois College of Veterinary Medicine -- A basic overview of CHF and what to look for.

Enacard (enalapril) -- Read all about it, including the cautions and suggested clinical observations that should be done for dogs on this drug.

Diuretics -- A page explaining the different types of water pills used in the treatment of CHF, what they do, and possible side effects.

Fortekor (benazeprilat) -- Novartis' own page about this heart medication sometimes used in CRF treatment for pets with heart failure.

Vetmedin (pimobendan) -- UK site. A new heart medication that has now been approved in Europe, Australia, New Zealand, and Canada. Also see VetGo Cardiology for a discussion of heart failure therapies, and pimobendan's beneficial effects.

All about CRF (Chronic Renal Failure) and Treatments

Canine Kidney Disease -- An overview of this subject with definitions and symptoms of Chronic as opposed to Acute Renal Failure, and more on dietary management including a few CRF recipes.

Chronic Renal Failure: What You Should Know -- Another good overview that includes standard treatment options in the US.

Renal Failure in Dogs -- Dr. Mike answers owners questions on this subject. Good for informational purposes; you must subscribe for a fee to ask your own question. (See also the Kidney Problems link on Dr. Mike's page.)

Kidney Disease -- Another explanatory page. Refers to cats, but much of the information is general and applies to dogs as well.

Kidney Disease in Dogs -- A page full of assorted helpful links, including breed specific information and one or two recipes.

Fluid and Electrolyte Therapy -- A technical explanation that gives insight into the use of fluid therapy and the sorts of fluids used in certain conditions.

Tanya's UK Feline CRF Information Centre -- Though it's about cats, CRF dog owners in the UK will still find this page invaluable.

Understanding Lab Results

Bill's Biochemistry Javascript -- Much of the online information regarding CRF comes from the States, which uses a different standard for measuring things like Urea (BUN) and Creatinine. If you're in the UK and want to compare your pet to cases cited in the US, this link will enable you to convert between umol/L and mg/dl for various indicators.

Interpretation of Lab Test Profiles -- Wonder what all those abbreviations mean on your pet's blood results? Wonder no more.

CRF Dietary Information

Nadia's CRF Homemade Diets -- Created with cats in mind, but the recipes can be used for dogs as well.

Canine Renal Disease -- This page has information including dietary suggestions.

The USDA's Nutrient Data Laboratory -- Gives breakdowns of nutrient values like protein in specific amounts of every food imaginable. Handy for keeping an eye on what you're feeding your CRF pet.